This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Sunday, 4 April 2010

Too many untrained staff.

I lost my mojo with writing a wee bit. But I thought I would update you on any new developments.

Awhile ago I explained that my trust was replacing real nurses with care assistants. And then they started replacing care assistants with untrained 17 year on "nursing cadets" who I like to refer to as "kids". Most of these kids have no interest in nursing. They take the job because it pays a little more than McDonald's and because they like to play around in the nurse uniforms. The few that do have an interest in nursing would be wondeful to have in addition to a well staffed ward. But instead they are all we have instead of a well staffed ward.

6 years ago we had 4 or 5 registered nurses and 3 or 4 healthcare assistants on a day shift for a large ward.

4 years ago it went down to 3 staff nurses and 3 care assistants.

Now we have 2 staff nurses and two cadets per shift on a good day. That means that they only people who can handle most of what is going on are the staff nurses. The cadets can do very little outside of bed pans. And many are not willing to even do that.

The health care assistants are leaving. The qualified nurses are leaving and they are all being replaced with untrained cadets. Being untrained (and young) means that even though they are counted in the staffing numbers, there is very little that they can do or understand about what is happening on the ward.

The cadets call off sick constantly. We are talking at least twice a week.. Weekend call offs are a given because teenagers like to get drunk.

They walk up and down the ward with mobiles. They talk to the patients like idiots. Some try to copy the staff nurses in their interactions with patients but they don't really know what they are on about. I once stood outside of a room eavesdropping on a patient telling a cadet that she thought she had a UTI as it burned when she passed urine. The patient probably assumed that the cadet was a nurse. "Is your pain radiating anywhere? Like to your left arm?" asks the cadet. At that point I went into the room, trying to keep a straight face. When I get student nurses on the wards I need to use them to babysit the cadets rather than teach them how to be a nurse.

We have to remember that the patients assume that these kids are some kind of Nurse. Most are not even wannabee nurses. They have had NO training. The few in number qualified nurses are so on their knees that we cannot watch these kids or avoid delegating the basic care to them. It gives me nightmares. I have not a minute free to teach them. This is why the cadets are only great in addition to real staff, not instead of real staff. The qualified nurses are unable to find jobs. But we are getting batch after batch of cadets. And the trust tells the world "oh yes indeed we are increasing our nursing numbers". There should be some kind of law that says that an NHS trust is only allowed to use the term nurse when they are actually talking about qualified nurses. That would bring stats down.

It is getting pretty obvious that these kids are not being vetted properly. We have had kids caught red-handed stealing drugs after asking for the keys to "get some sudocrem". We have had kids who have been found out to have a criminal record when they were once again arrested for assault. We have kids who are coming to work hungover. All sorts of alleged social problems stop these kids showing up for work much of the time. One kid's boyfriend showed up on the ward and got into a physical altercation with her. We have 16 year old pregnant kids who refuse to lift-the only thing that they are allowed to do anyway.

Thank god for the one or two cadets who are planning on nursing or medical school. They are there for the right reasons and take pride in their work. The rest of them are crap.

We have 4 decent health care assistants left. Three of them handed in their notice along with a qualified nurse who has had enough. In their place, we care getting 4 of these cadets. The experienced health care assistant that is left has told the managers in no uncertain terms that she has had enough of the cadets and is refusing to work with them from now on. The qualified nurses feel the same.

One of our qualified nurses was the sole RN for 30 beds with 2 cadets on a monday morning. It was hell on and she was ringing and ringing and begging for more help. They kept sending her more cadets and acting like the nurse would be fine as long as she had a "few more sets of hands". This is how badly management devalues nurses. They think that untrained chavs can do the job and help the nurses. The qualified nurse broke down completely and resigned. And she is getting replaced with a cadet. And the public thinks that these cadets are their new "modern nurses" who have been "ruined by university". Wrong. Most of these cadets probably never even finished high school. And they are of no help to us when we are low on qualified nurses. The real new and modern nurses are stocking shelves as Asda because they cannot find a job.

24 comments:

Anonymous
said...

"This is how badly management devalues nurses".

I have no idea, of course, if this is true or not, but it is your perception and that's what counts, but as a senior nurse myself, can I ask what the nurse on your executive team has to say about this matter? I would assume that she/he is promoting nursing and putting a case forward for appropriate (registered)staffing levels.

As experienced staff nurses leave our A&E department (due to being totally demoralised), they are being replaced ONLY by newly-qualified nurses (cheaper). Experienced applicants do not get a look in. So, now we have a bunch of newby's running the show.

Just like Stafford - where it was shown that nurses did not know how to read cardiac monitors, or look after critically ill patients etc. I suspect Stafford also went down the route of employing only newly qualified nurse too - because they are so much cheaper.

Once upon a time you needed 6months ward experience to work in A&E, because that's what it takes. Nowadays, nurses with experience are too expensive.

So we have newby's teaching newby's. We'll end up like Stafford too. And the poor nurses will get the blame (in the eyes of the public), just like Stafford.

Glamorganist - you should get into the real world. If the RN had to abandon her duties to unlock cupboards every time someone needed somethin out of a locked cupboard, people would be seriously neglected by that RN in the mean time...

Just like they are neglected when the RN has to act as ward clerk - as there is not enough funding to provide a bloody ward clerk.

Anonymous, you are quick to challenge my credentials (in response to your irrelevant "ad hominem" comment, I do in fact live in the real world and spent 37 years in the real world of nursing practice) but you don't actually deal with my question. Does your response indicate that you think it is acceptable to give unqualified people access to the drugs cupboard? If so, I find your attitude irresponsible and dangerous, not to say foolish.

To return to my original point, perhaps you, or any other reader of this blog, could tell me why, in Anne's story, the keys to the store cupboard used for external medications (Sudocrem) appear to be kept on the same key ring as the keys to the drug cupboard. If the keys were organised separately then the issue you and Anne describe would not arise. Cadets could be given the key to the external medications cupboard and have access to the supplies they legitimately needed while the security of the drug cupboards would not be compromised. Is such a solution too difficult? Or impossible for some other reason?

Nurse Anne I am not being funny but do you realise that some HCA's Nurse Auxilary's, Support Worker's and Nurse Cadets are also reading your blog it sounds like you a vendetta against them give a break, it is actually quite hurtful.

Glamorganist - out of the last 37 years, when did you last work as an RN on the wards? Bacause staffing and stress has changed an awful lot over the 10 years that i have been nursing on the wards. Todays nursing is hell.

Anonymous: in neither of your two responses to my comment have you actually addressed the points I made. Why don't you do that instead of trying to change the subject? Then we might have a productive discussion about this aspect of nursing practice.

As a victim I would agree with what has been posted from 1st hand experience. The Management fat cats take the cream, the Matron bullies and covers up neglect. Doctors don't know how to examine it is beneath them. There are some good old fashioned nurses who work so hard and there are those who should not be left in charge of a dead animal in a cage. That is the sad fact, and proveable, in my case and like many others. The NHS needs a goood clean up, the public expect a reasonable quality of care, when desparately needed. They do not need to be dehydrated with terrible bleeding bedsores just as a minor side effect of having to be in an MHS hospital in 2010. Make management culpable by dismissal and prison, same with nurses and doctors who are proven to be useless. Are there too many people with special interests for this to happen? Unless staff stand up and be counted they will be like many I know SNR Nursing officers working tills. Nursing is a vocation, the public do not want the NHS privatised through the back door.

There are some really conscientious dedicated nursing assistants but unfortunately because they just glide around efficiently doing a really good job they don't get noticed. It is the loud-mouthed ones, those who don't give a damn about the patients, or describe themselves as 'the real nurses' who are the problem. I always made a point of thanking the good support workers and telling them how much I appreciated them because it was true, they were sensible, reliable and made my work so much easier. I had a good laugh one day though. One auxiliary who was a sly little minx always trying to cause trouble went up to a visitor and haughtily ordered her to wash her hands - unfortunately for her the woman was a matron from another area who knew exactly what this girl's uniform signified and much to my joy gave her a right royal 'ear-bashing' along the lines of don't teach your granny to suck eggs and don't ever speak to visitors like that again etcetera. I'd like to say this cured her of her delusions of grandeur but she was soon back to her old tricks.

I was doing a 13 hour shift working alone looking after a group of patients (no cadet, HCA, support worker at all available to assist). In plain English rather than nursing terms (so Joe public can understand) my patients were all heavy and immobile (so had to use hoists to move them) doubly incontinent (urine & poo). Two-thirds of them had to be fed via stomach PEG or RIG, some were brain-damaged and confused. This group also included the violent, the terminally ill, plus a non-English speaking immigrant. I had to do all the bog-standard stuff such as wash, dress, change beds, numerous four-hourly tube-feeds, dressings, obs, meds, document, fluid-balance charts, BM's, prepare for surgery and loads of other stuff. By evening I'm punch-drunk with exhaustion when suddenly a female in uniform appears and berates me loudly for failing to feed patients in another room and reprovingly reminds me "we are all supposed to help each other out you know". The visitors look on pityingly as I am obviously being reprimanded by a VSN i.e. a very senior nurse. But dear reader all is not as it seems. For a start she is not a senior nurse, she is one of the lowest ranking members of the team. She has not had any formal training, probably hasn't even got a basic anatomy and physiology GCE. It is not her place to reprimand me, on the contrary she is beneath me in rank and it is my job to give her orders not the other way around. The patients she fed were not my group. I had given 20+ tube feeds that day and had fed several of my patients by hand as well. She had more than enough spare time to feed those patients in the other part of the ward particularly as she spends most of her days laughing and joking but then you can do that when you don't have any real responsiblities. She can't put up drips or give drugs or injections etc but gullible Joe public doesn't understand that. She can't describe the different types of shock or understand the composition of blood etc but Joe public doesn't know that either. They just see that she is looking self-righteous, indignant and disapproving therefore it follows that she must obviously be someone important and in authority right? No wrong actually, she is just trying to pull the wool over the eyes of the poor confused gullible visitors and hey, it seems to be working.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.